Better care through deeper understanding of policy and economics

Physicians go through years of preparation for their roles as healers, but one domain with significant clinical implications receives little or no emphasis in medical training: health care policy and economics. A new textbook includes foundational instruction on the topic and a framework for its incorporation into medical school curricula.

“Most physicians and students feel that health policy is something doneto them, rather than with them,” said Matthew M. Davis, MD, professor of pediatrics and medical social sciences at Northwestern University Feinberg School of Medicine. “And when physicians feel powerless, they can lose sight of all the options available to them in helping patients. My coauthors and I want to bring physicians and medical students squarely into the middle of the policy discussion.”

Dr. Davis, a pediatrician-internist and head of the Division of Academic General Pediatrics and Primary Care at Ann & Robert H. Lurie Children’s Hospital of Chicago, is the lead author of the “Health Care Policy and Economics” chapter in Health Systems Science. This is a new textbook that defines and codifies the emerging “third pillar” of medical education and provides a framework for its implementation nationwide.

In writing the chapter, Dr. Davis and his co-authors—Mark D. Schwartz, MD, of the New York University School of Medicine and Elizabeth Tobin-Tyler, of the Warren Alpert Medical School of Brown University—sought to tackle arguably one of the greater curricular needs in medical education.

“My research colleagues and I took a look at more than a decade of data from medical students graduating from U.S. allopathic schools,” Dr. Davis said. “What we found was that health care policy and economics is the topic about which students have the lowest confidence. That was a strong signal that we needed to rethink and rework how medical students learn about health policy and economics. This new chapter is part of that effort.”

By teaching students about the main stakeholders in the U.S. health care system and their respective economic interests, he said, it becomes much clearer for learners why the U.S. health care system functions the way it does.

“One key example is the role of insurance coverage in the U.S. health care system,” Dr. Davis said. “Although the relationship between physicians and insurance companies may feel antagonistic for many physicians, the fact is that insurance coverage is vital in helping patients pay for the advanced care that U.S. physicians provide. Without insurance plans, most patients would not be able to afford care.

“In addition, the growing role of government-sponsored health coverage in our system, like Medicare and Medicaid, is also linked to the fact that private insurance plans are too expensive for economically vulnerable populations, such as seniors on fixed incomes and poor families,” he added. “While many physicians may be critical of government-sponsored coverage and the constraints in reimbursement it may impose, those plans provide critically important support for over 100 million patients today, without which the costs of their medical care can lead to personal bankruptcy.”

Time is right for teaching

One of Dr. Davis’ goals is to put medical students at ease with the subject of economics, given that most focused on the sciences in their undergraduate preparation for medical school.

“A lot of the systems that we teach about in medical school—the organ systems, the problems that lead to disease—are extraordinarily complex,” he explained. “I believe the health care system is less complex than a lot of the physiologic concepts and biochemical concepts that are taught, and mastered, by many medical students.”

Fortunately, medical schools don’t need to reinvent their curricula to accommodate health care policy and economics. In fact, Dr. Davis said, often the best approach is to integrate it into existing coursework.

“For example, when we teach about the development of new medications, we can teach about the policy issues related to the drug-approval process and the drug-pricing questions that are raised in public programs like Medicare Part D that pay a large share of the costs of drugs for seniors,” he explained. “We can also talk about the policy issues for private insurance plans that often set up different tiers or levels of copayments for families for brand versus generic drugs. Research we’ve conducted shows that medical schools that weave policy in with other nonpolicy topics help their students grasp these concepts and feel more confident about their knowledge, without sacrificing the time necessary for teaching other core material.”

Policy informs practice

Formalizing health care policy and economics in medical teaching, Dr. Davis said, can change how physicians practice and help improve outcomes for patients.

“When I supervise residents and medical students in clinic, they talk to me about the clinical problems they’ve just learned about from their patients, and I pose the question to them, ‘So which policy issues are affecting this patient?’” he said. “Initially, students are puzzled. They say, ‘What do you mean? Which policy issues?’ because they haven’t been trained to think about how policy relates to clinical questions.

“But every patient has policy issues that affect their care. For example, what is the structure of the patient’s health plan regarding deductibles, coinsurance and copayment for this visit? What will he or she pay for the prescription that we’re writing today? How is their access to insurance affected by the state where they live? There are all these policy questions that are right in front of us, and by spotting them and understanding them better, I firmly believe we’re able to provide better care for our patients.”

Focus on principles, not presidents

Health care policy and economics is necessarily getting special attention in the national debate over repealing and replacing the Affordable Care Act, but Dr. Davis says it has always been, and always will be, a relevant topic.

“With every change in presidential administration, there’s usually a key modification in federal health policy,” he said. “In other words, change is normal, and we’ve just gone through eight years of the biggest change in our health care system since the 1960s, when Medicare and Medicaid were put in place.

“It’s much more helpful for students to learn the fundamentals of the system than to try to track specific program changes led by each new administration. So rather than focusing exclusively on programs, we look at the principles behind those programs. It’s those principles that the medical students of today will apply as the physicians of the future.”

Health Systems Science, parts of which are already in use in medical schools across the country, was coauthored by experts from the AMA and faculty from 11 of the 32 member schools in the AMA’s Accelerating Change in Medical Education Consortium. Dr. Davis completed this chapter when he was part of the faculty of the University of Michigan Medical School, which is a consortium member. The book’s content is intended to be relevant to all learners within the health professions.

The book retails for $59.99 and can be ordered from the AMA Store and the publisher, Elsevier, as well as from Amazon and other online booksellers. AMA members may order it from the AMA Store for $54.99. Individual chapters will also be available from Elsevier for $6.99 each.